COLUMBIA, Mo. (AP) — The Truman Memorial Veterans’ Hospital failed to provide a safe environment for a 78-year-old man who was beaten to death last year at the Columbia facility, according to a VA report.

The report by an administrative board of investigation for the Veterans Affairs Heartland Network was included in materials released by the VA in response to a Freedom of Information Act request by The Columbia Daily Tribune (http://bit.ly/1kwukiy ).

The report detailed what happened at the hospital when Rudy Perez Jr., 34, assaulted and killed Robert O. Hill, of Warsaw, on Feb. 1. Hill was a patient and Perez was there on a 96-hour involuntary commitment from Pettis County after an alleged assault on his father. Perez’s lawyer, David Tyson Smith, said Perez was having a psychotic episode when the events began that led to his admission to Truman.

Perez, of Sedalia, was charged with first-degree murder in Hill’s beating death. He was acquitted Sept. 23 when Boone County Circuit Judge Gary Oxenhandler accepted his plea of not guilty by reason of insanity after two psychiatric evaluations determined that Perez was “driven by psychosis.” Perez was remanded to the custody of the state Department of Mental Health and is in a maximum security unit of Fulton State Hospital.

According to the investigators’ report, the VA police officer “was not advised of any incidents which precipitated the 96-hour hold” on Perez. Outside law enforcement agencies did not routinely provide information concerning police incidents before patients are transferred to the Columbia hospital, the report found.

The investigative board identified several contributing causes, including ineffective hand-off communication related to a history of violence; lack of consistent, reliable communication between law enforcement agencies; reluctance to use restraint, and failure to provide a safe, alternate environment.

Hospital spokesman Stephen Gaither said Truman has taken measures to increase communication with other law enforcement entities. It also has created new policies, sought to hire a new full-time attending psychiatrist and started training staff on the prevention and management of disruptive behavior.

Gaither said the new assault policy makes it clear that restraints can be used when a clinical decision deems them necessary.

Doctors are also required to notify and document communication between departments when a patient is moved to the inpatient unit. Nursing personnel also are required to have a safety plan in place for patients who have been assaulted when they return to the unit, Gaither said.

Truman’s chief of staff, Lana Zerrer, said the staff is also working to improve communication with police on mental health training and jurisdictional issues.

“When a patient comes in to a psychiatric unit, we look at things like if they’ve assaulted anyone recently, if they have active psychosis and if they’re on withdrawal from a substance” and give them a risk assessment score, Zerrer said.

Zerrer, however, defended the staff.

“When you know what the staff knew at the time of the incident, it’s debatable,” she said. “It’s hard to say they should have done anything differently.”